Lack of coverage is the primary short-term disability disqualifier.
Hundreds have asked us how to apply for benefits, thinking the government had a program replacing lost wages.
But this belief is wrong. Forty-one states do not require temporary disability.
If you get sick, hurt, or pregnant, it may be too late to buy a policy from a private insurer. Even if you can get coverage, the insurer will exclude benefits for pre-existing conditions for a defined period.
Learn the rules and find alternatives.
Reasons for Claims Denials
There are many reasons why an insurance company might deny your claim for short-term disability benefits. Please do not allow a lack of coverage to be one of them.
Government expense reduction benefits become the only alternative if you lack coverage. A lower income from lost wages can help you qualify for these programs.
Policy Exclusions
Insurance companies frequently deny the claims of short-term disability policyholders due to specific exclusions. You might find some of these disqualifying clauses in your policy documents.
Pre-Existing Condition
A pre-existing health condition is the most frequent claim disqualifier during the first twelve months the policy is active. Your outline of coverage might include several phrases similar to these.
- A pre-existing condition means having a sickness or injury for which you were treated, got medical advice, or took medication within 12 months before this policy started.
- Suppose you become disabled due to a pre-existing condition. In that case, we will not pay benefits for any disability period starting in the first 12 months of the policy.
Already Pregnant
Becoming pregnant before the policy’s effective date disqualifies many women from benefits during the first nine months. Your outline of coverage might include an exclusion similar to this one:
We will not pay benefits for normal childbirth, including Cesarean if conception occurred before 30 days after the policy started.
Mental Health
Many issuers of individual policies reject claims for mental health problems because they are not covered conditions. Your outline of coverage might include an exclusion similar to this one:
We will not pay benefits for losses caused by:
- A mental or emotional disease or disorder, including psychoneurosis, psychopathy, and psychosis
- Addiction to alcohol or drugs, except drugs prescribed by your doctor
Risky Activities
Many insurers will rebuff claims caused by risky activities. Your outline of coverage might include many of these specific exclusions:
- Participating in a felony, riot, or insurrection
- Attempting suicide or self-injury
- Exposure to an act of war
- Serving in the armed forces
- Operating a private aircraft (no published schedule)
- Working an illegal job
- Riding or driving in a motor vehicle race or stunt
- Participating in a sport for pay
Paperwork Mistakes
Insurance companies and state agencies frequently reject short-term disability claims because of incomplete documentation and other simple paperwork mistakes. Fortunately, you have a second chance to correct these errors.
Read the instructions carefully and speak to a claims adjuster to identify the problems. Careless mistakes often have profound consequences.
For instance, a missing signature or date on any one of three claim form sections can lead to declination.
- Policy owner: certifying the answers are correct
- Employer: verifying the loss of income
- Physician: specifying the diagnosis that prevents the patient from working
Policy Features
Standard short-term disability features lead insurance companies to refuse claim requests. The outline of coverage should describe two features that every policy has.
- Elimination Period: defines when claim payments start. You are ineligible for benefits until you meet the specified time frame of 7, 14, 30, 60, or 90 days.
- Benefit Period: defines how long claim payments last. Your benefits will stop after the specified time frame of three, six, twelve, or twenty-four months.
Reasons for Coverage Denials
Insurance companies have many reasons for denying short-term disability coverage to applicants seeking a new policy. Avoiding costly claims is their primary motivation for turning away new customers.
Buying coverage before getting sick or injured is the best way to avoid rejection. Do not assume the government will cover all your needs.
Poor Health
A recent history of poor health is why insurance companies deny coverage to most prospective policyholders. People who were sick in the past are more likely to be ill again.
Insurers are more lenient with large employer groups because they can pool risks. At the same time, they are stricter with individual policies bought outside of work.
Individual
Insurers are more likely to decline applicants for individual coverage because they cannot share risks with other employees. Therefore, expect to encounter comprehensive health history questions like the following.
“Have you received medical advice, sought treatment, or taken medication for any of these conditions in the last five years?”
| Heart Attack | Heart Surgery | High Blood Pressure |
| Heart Disease | Stroke | Transient Ischemic Attack |
| Cancer | Kidney Disease | Diabetes |
| Emphysema | Lung Disease | Liver Disease |
| Hepatitis | Cirrhosis | Neurological Disorder |
| Multiple Sclerosis | Chronic Fatigue Syndrome | Fibromyalgia |
| Intestinal Disease | Alcohol or Drug Abuse |
Group
Insurers are less likely to reject new policy applicants enrolling at large employer groups because they can pool risks with co-workers. Therefore, expect to encounter narrow health history questions like the following.
- “Have you ever been treated for or diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or tested positive for Human Immunodeficiency Virus (HIV)?”
- “In the past 12 months, have you received medical advice, sought treatment, taken medication, or been hospitalized for cancer (except basal cell skin cancer), insulin-dependent diabetes, or cirrhosis?”
Sign up during the first available opportunity at work. Insurers typically offer these more lenient group qualifiers once. If you pass the first time, expect stricter criteria the next time.
Missed Work
A recent episode of missed work is another reason insurance companies might reject new policy applicants. Employees unable to perform their work duties in the past are more likely to file future claims.
Therefore, you should expect questions about work absences, such as the following.
“Have you missed five or more consecutive work days in the past 12 months for any injury or illness other than cold, flu, or maternity?”
Excess Weight
Being morbidly obese is another reason insurance companies deny coverage to prospective policyholders. People who are excessively overweight are more likely to file claims for joint disorders and other chronic illnesses.
The new policy application might ask about your height and weight so the underwriter can calculate your Body Mass Index (BMI). If so, expect an instant rejection if your BMI exceeds 38, as shown in these examples.
| Height (Feet & Inches) | Weight (Pounds) |
| 5′ 0″ | 195 |
| 5′ 6″ | 237 |
| 6′ 0″ | 278 |
